Incidence and predictors of early and late hospital readmission after transurethral resection of the prostate: a population-based cohort study.

OBJECTIVES: To evaluate the incidence and predictors of hospital readmission and emergency department (ED) visits in patients with benign prostatic hyperplasia treated by transurethral resection of the prostate (TURP). PATIENTS AND METHODS: We conducted a retrospective cohort study using a linked administrative dataset from Calgary, Canada. Participants were men who underwent their first TURP procedure between 2015 and 2017. We examined patient demographics, and type of surgery (elective or urgent). Comorbidities were scored using the Charlson comorbidity index (CCI). The primary outcomes were unplanned hospital readmissions and ED visits at 30, 60 and 90 days after TURP. The secondary aim was to identify potential predictors across these groups. RESULTS: We identified 3059 men, most of whom underwent elective TURP (83%). The mean (sd) patient age was 71.0 (10.0) years. A total of 224 patients (7.4%) were readmitted to the hospital within 30 days, 290 (9.5%) within 60 days, and 339 (11.1%) within 90 days of discharge. The frequency of return visits within 30, 60 and 90 days of TURP were 21.4%, 26% and 28.6%, respectively. The most responsible diagnoses for ED visit within 90 days were haematuria (15.4%) and retention of urine (12.8%). Multivariable analysis showed that age (odds ratio [OR] 1.61, P < 0.001), surgery type (OR 2.20, P < 0.001), and CCI score (OR 2.03, P < 0.001) were independently associated with odds of readmission and ED visits at all time points. CONCLUSION: Older age, poorer health and urgent surgery predicted return to ED or readmission after TURP; efforts should be made to improve selection, counselling and preoperative optimization based on these risks.

Natural History, Complications and Re-Intervention Rates of Asymptomatic Residual Stone Fragments after Ureteroscopy: a Report from the EDGE Research Consortium.

PURPOSE: Fragments 4 mm or smaller after ureteroscopy historically have been considered clinically insignificant but there is a reported 20% event rate on followup even with stones 4 mm or smaller. In this study we examine the natural history, complications and re-intervention rates of fragments after ureteroscopy. MATERIALS AND METHODS: Data from 6 centers were collected retrospectively from members of the Endourology Disease Group for Excellence in 232 patients who had residual fragments after ureteroscopy between 2006 and 2013. Patients with fragment(s) of any size on imaging within 12 months were eligible. The primary outcome measured was stone events, and secondary outcomes included stone growth, stone passage, re-intervention and complications. RESULTS: Of the 232 subjects with fragments 131 (56%) required no further intervention and remained asymptomatic, 34 (15%) experienced complications requiring no intervention and 67 (29%) required intervention, ie the primary outcome stone event rate was 44%. Fragments larger than 4 mm were more likely to grow with time (p <0.001) and were associated with more complications (p=0.039). Fragments larger than 2 mm were more likely to grow (p <0.001) but were not associated with complications or re-intervention. Re-intervention was predictable based on fragment size (p=0.017). In a multivariable logistic regression model there was no significant difference between the techniques of dusting stones or basket extraction. CONCLUSIONS: This study suggests that fragment size larger than 4 mm after ureteroscopy is associated with significantly higher rates of stone growth, complications and the need for re-intervention. Ensuring complete stone-free status is the most effective strategy to reduce stone events after ureteroscopy.

Baseline patient reported outcomes data shows high prevalence of overactive bladder, sexual dysfunction, depression and anxiety in Canadian men with newly diagnosed localized prostate cancer.

BACKGROUND: Research on prostate cancer survivorship patients has largely been on oncological outcome, incontinence and erectile dysfunction, with less data on the relationship between prostate cancer, bladder function and mental health. This study aims to elucidate the prevalence of lower urinary tract symptoms (LUTS), overactive bladder (OAB), sexual dysfunction, depression and anxiety in Canadian men with newly diagnosed localised prostate cancer. METHODS: This is a single-centre prospective cross-sectional study of men with newly diagnosed localized prostate cancer recruited from June 2017 to July 2018. The patient-reported outcomes (PRO) instruments used in this study included the international prostate symptoms score (IPSS), OAB-V8, EQ-5D™, and the Expanded Prostate Cancer Index Composite short form (EPIC-26). Clinico-pathological data were extracted from medical records. The prevalence of LUTS, OAB, sexual dysfunction, depression and anxiety were determined from the PROs. RESULTS: A total of 83 patients were included in this study. The median age was 63. Based on IPSS scores, 55.3% of men had mild LUTS, 36.8% had moderate LUTS and 7.9% had severe LUTS. Based on OAB-V8 scores, 55.8% of men had a score of 8 or higher, suggestive of OAB. Only 55.8% of men reported erections adequate for intercourse. 23.1% of men reported to have a moderate to big problem with depression, and 28.8% of men reported to have a degree of anxiety or depression. CONCLUSIONS: OAB is a significant problem in men with newly diagnosed localized prostate cancer, with a prevalence of 55.8% based on this study. Baseline sexual dysfunction, anxiety and depression are also prevalent in this population.

A Decision Analysis of Observation vs Immediate Reintervention for Asymptomatic Residual Fragments Less than 4 mm Following Ureteroscopic Lithotripsy.

INTRODUCTION: We performed a decision analysis model of the cost-effectiveness of observation vs intervention for asymptomatic residual fragments less than 4 mm in diameter following ureteroscopic holmium laser lithotripsy. METHODS: Outcomes data from a retrospective analysis evaluating the natural history, complications and reintervention rates of asymptomatic residual stone fragments performed by the EDGE (Endourology Disease Group for Excellence) Research Consortium were used. A decision analysis model was constructed to compare the cost-effectiveness of initial observation of residual fragments to immediate intervention. Cost of observation included emergency room visits, hospitalizations and reinterventions. The cost analysis model extended to 3 years to account for delayed reintervention rates for fragments less than 4 mm. Costs of emergency department visits, readmissions and reinterventions were calculated based on published figures from the literature. RESULTS: Decision analysis modeling demonstrated that when comparing initial observation to immediate reintervention, the cost was $2,183 vs $4,424. The difference in cost was largely driven by the fact that over 3 years, approximately 55% of all patients remained asymptomatic and did not incur additional costs. This represents an approximate annual per patient savings of $747, and $2,241 over 3 years when observation is selected over immediate reintervention. CONCLUSIONS: Our decision analysis model demonstrates superior cost-effectiveness for observation over immediate reintervention for asymptomatic residual stones less than 4 mm following ureteroscopic lithotripsy. Based on these findings careful stratification and selection of patients may enable surgeons to improve cost-effectiveness of managing small, asymptomatic residual fragments following ureteroscopic lithotripsy.

Complications, Re-Intervention Rates, and Natural History of Residual Stone Fragments After Percutaneous Nephrolithotomy.

INTRODUCTION: The management of residual fragments (RFs) that persist after percutaneous nephrolithotomy (PCNL) has been poorly studied. Fragments have the potential to grow or cause symptoms. The aim of this study was to follow patients with fragments after PCNL to identify predictors of stone-related events (re-interventions and complications) after PCNL. PATIENTS AND METHODS: Data were retrospectively collected from patients who underwent surgery from 2008 to 2013 at our hospital. Patients with fragments of any size on postoperative day 1 computed tomography of the kidney, ureter, and bladder radiograph (CT-KUB) were included, and patients with planned secondary interventions were excluded. Subgroup analysis was performed on subjects with CT-plain X-ray to determine fragment growth or passage. RESULTS: Of the 658 patients who received a postoperative CT-KUB on day 1, 299 patients (45%) had fragments that were 1 mm or larger. From this, 263 patients met the study criteria and were included. The size of fragments, using a 4 mm cutoff, did not predict the passage of fragments (p = 0.173) or growth (p = 0.572). On multivariable logistic regression analysis, previous history of renal stones and size of fragment were found to be predictive for stone-related events (p = 0.002 and 0.027, respectively). Kaplan-Meier analysis identified patients with fragments >4 mm having a shorter survival time before the occurrence of stone-related events (p = 0.044). CONCLUSIONS: The true stone-free rate was 55% after PCNL. However, 82.5% were stone free or had RFs 4 mm or less, which correlates with previous studies. Larger RFs had higher rates of stone-related events and shorter time to occurrence of stone-related events. The growth and spontaneous passage of RFs was independent of RF size, emphasizing the importance of obtaining a stone-free status after PCNL.

Anticholinergics for overactive bladder: Temporal trends in prescription and treatment persistence.

INTRODUCTION: We sought to understand the contemporary pharmacologic management of overactive bladder (OAB) in a single-payer system. We examined temporal trends in the use of anticholinergic medications and assessed whether the likelihood of patients changing their anticholinergic therapy was predicted by their current therapy. METHODS: We conducted a retrospective, population-based analysis of prescription records from the PharmaNet database in BC, Canada. We identified patients treated with one or more anticholinergic prescriptions between 2001 and 2009. We characterized temporal trends in the use of anticholinergic medications. We used generalized estimating equations with a logit wing to assess the relationship between the type of anticholinergic medication and the change in prescription. RESULTS: The 114 325 included patients filled 1 140 296 anti-cholinergic prescriptions. The number of prescriptions each year increased over the study, both in aggregate and for each individual medication. While oxybutynin was the most commonly prescribed medication (68% of all prescriptions), the proportion of newer anticholinergics (solifenacin, darifenacin, and trospium) prescribed increased over time (p<0.0001). Patients taking tolterodine (odds ratio [OR] 1.03; p=0.01) and darifenacin (OR 1.12; p=0.0006) were significantly more likely to change their prescription than those taking oxybutynin. There was no association seen for patients taking solifenacin (p=0.6) and trospium (p=0.9). CONCLUSIONS: There are an increasing number of anticholinergic prescriptions being filled annually. Patients taking newer anticholinergics are at least as likely to change therapy as those taking oxybutynin. The reimbursement environment in BC likely affects these results. Restrictions in the available data limit assessment of other relevant predictors.

Advances in ureteral stents.

Ureteral stents are commonly used in urology. Every urologist is familiar with the problems that are associated with stents including infection, encrustation, and bothersome symptoms. These problems limit and affect the use of ureteral stents which are necessary, even in light of the problems they can cause. New designs such as a helically cut ureteral stent which is designed to stretch and conform to the ureter is designed to improve comfort. Drug-eluting designs with an antimicrobial (triclosan) are designed to reduce bacterial adherence to ureteral stents. Chlorhexidine, an antiseptic, has been incorporated into a stent and held in place by a slow release varnish to prevent biofilm formation. Combinations of antibiotics coated directly on the stent and administered systemically have been shown to reduce stent colonization both in vitro and in vivo. Gel-based ureteral stents were also showed to reduce bacterial infection and colonization. Bioabsorbable materials have also been designed to reduce infection, symptoms and prevent the forgotten stent syndrome. Newer designs including stents based on guidewire technology, gels, and a combination of self-expanding wire stents with polymer films are reviewed. There is hope on the horizon that new stents will be able to effectively tackle problems that are often seen with ureteral stents.

Testosterone deficiency syndrome and cardiovascular health: An assessment of beliefs, knowledge and practice patterns of general practitioners and cardiologists in Victoria, BC.

INTRODUCTION: Testosterone deficiency syndrome (TDS) has been shown to be an independent cardiovascular risk factor and a predisposing factor for metabolic syndrome. As general practitioners and cardiologists primarily care for these patients, we sought to assess their knowledge, beliefs and practice patterns with respect to TDS and cardiac health. METHODS: We distributed a questionnaire to all 20 cardiologists and a cohort of 128 family practitioners in Victoria, British Columbia. Of the 13 questions, 10 assessed knowledge and beliefs on TDS and 3 assessed current practice patterns. RESULTS: Most respondents believed that TDS is a medical condition (66.7%) and could negatively affect body composition (62%), but a similar majority was unsure whether it was a cardiac risk factor (66.7%). While most believed that testosterone replacement therapy (TRT) could improve exercise tolerance (62%), most were unsure if it was beneficial in cardiac patients. Cardiologists were significantly less likely to believe that TRT was beneficial in preventing recurrent myocardial infarction and improving myocardial perfusion (p = 0.0133, 0.00186, respectively). The vast majority (88%) did not screen cardiac patients for TDS. If a patient was identified as having TDS, only10% of those surveyed would refer these patients to a urologist. CONCLUSION: Despite its prevalence in cardiac patients, TDS is not well-understood by general practitioners and cardiologists; they lack knowledge on its deleterious cardiovascular effects. In their role as men's health advocates, urologists should educate our colleagues regarding the correlation between TDS and cardiovascular mortality and risk factors. Limitations of this study include small sample size and restricted geographic scope.

A surgical challenge: Idiopathic scrotal elephantiasis.

Scrotal elephantiasis is a condition rarely encountered in developed nations. It is endemic in tropical regions due to the presence of filariasis (Wucheria bancrofti). We report 2 cases of idiopathic scrotal elephantiasis in Canadian citizens with no history of travel to endemic filariasis regions, malignancy, surgery or radiation. Both patients underwent complete excision of the involved tissue with reconstruction. We found that for advanced cases of scrotal lymphedema, surgery is currently the only solution. In our cases of advanced idiopathic disease, surgical treatment combining the expertise of a plastic surgeon and a urologist provided a successful functional and cosmetic result.